Answers
The nurse reviews assessment data on a group of patients. Which patient should the nurse identify as
experiencing a critical illness?
1. Chronic airflow limitation with VS: BP 110/72, P 110, R 16
2. Acute bronchospasm with VS: BP 100/60, P 124, R 32
3. Motor vehicle crash with VS: BP 124/74, P 74, R 18
4. Chronic renal failure on hemodialysis with no urine output with VS: BP 98/50, P 108, R 12 - ANSWER:2
Which patient should the nurse expect to be transferred to a critical care unit? Select all that apply.
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1. Experiences an acetaminophen overdose
2. Diagnosed with an acute mental illness
3. Receiving treatment for chronic renal failure
4. New onset of acute decompensated heart failure
5. Treatment for bacteremia from an infected foot wound - ANSWER:1,4,5
The nurse employed in a hospital in a small rural town would expect to provide which level of care in the
critical care unit?
1. Level I
2. Level II
3. Level III
4. It is unlikely that the hospital would have a critical care unit. - ANSWER:3
With which individuals should the nurse expect to provide patient care in an "open" ICU?
1. Multidisciplinary team with physicians who are also responsible for patients on other units
2. Multidisciplinary team that includes a physician employed by the hospital
3. Physician in charge of patient care who is a specialist in critical care
4. Primary care physician who must consult a critical care specialist - ANSWER:1
What should the nurse who provides care to patients in a critical care unit realize the role of technology
is on the amount of errors?
,1. It relies heavily on human decision making.
2. Devices are programmed to function without double checks.
3. It makes the workload seem overwhelming to health care providers.
4. There is uniform equipment throughout each facility. - ANSWER:2
What should the nurse identify as an example of an installed forcing function or a system-level firewall to
prevent errors when providing patient care?
1. Prior to administration of insulin, two nurses check the dose.
2. Prior to obtaining a medication, height, weight, and allergies are recorded.
3. All medications are checked by two nurses prior to administration.
4. Undiluted potassium chloride is not available on critical care units. - ANSWER:4
The nurse realizes that the increased use of technology in critical care units has resulted in which
consequence for patient care?
1. Decreased risk of errors in patient care
2. Decreased therapeutic nurse-patient communication
3. Improved overall patient satisfaction with care
4. Improved patient safety across the entire spectrum - ANSWER:2
The nurse in the critical care area is completing a preoperative checklist before sending a patient for
surgery. This nurse's activity is an example of which recommendation issued by the Institute of
Medicine?
1. Utilizing constraints
2. Simplifying key processes
3. Avoiding reliance on vigilance
4. Standardizing key processes - ANSWER:3
Which actions should the nurse complete after realizing that an incorrect dose of medication has been
administered to a patient? Select all that apply.
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1. Notify the patient and family.
2. Notify the physician.
3. Document the error.
4. Prepare for an analysis of the error.
,5. Keep the notification of the error silent. - ANSWER:1,2,3,4
The nurse working within the AACN Synergy Model realizes that optimal patient outcomes are realized
when:
1. Highly qualified nurses care for patients in highly technical settings.
2. Nurses agree to work overtime to cover unit staffing needs.
3. Staff nurse competency is matched with patient needs.
4. Patient care is delivered within a "closed unit" model. - ANSWER:3
Which actions by the critical care nurse demonstrate an understanding of patient advocacy? Select all
that apply.
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1. Maintaining attendance at the bedside with the patient during a physician visit
2. Assisting and supporting the patient and family as they reveal their needs
3. Alerting the physician to concerns about client placement after hospitalization
4. Encouraging and supporting a patient's spouse in preparing for a family meeting
5. Seeing the big picture when planning patient care - ANSWER:1,2,3,4
A nurse is preparing to communicate an issue about patient care to a physician using the SBAR
technique. Which phrase is an appropriate initial statement?
1. "I am concerned about..."
2. "The patient's immediate history is..."
3. "I think the problem is..."
4. "I would like you to..." - ANSWER:1
Which statement should the nurse include for "A-Assessment" in the SBAR technique for
communication?
1. "I think the problem is..."
2. "The patient's vital signs are..."
3. "The patient's treatments are..."
4. "I would like you to..." - ANSWER:1
Which statement should the nurse use when concluding SBAR communication about a patient issue?
1. "The patient's immediate history is..."
2. "The patient's physical findings are..."
, 3. "I am requesting that you..."
4. "I have assessed the patient personally." - ANSWER:3
The nurse collaborates with other members of the health care team to effect optimal outcomes in
patient care. Which characteristics of emotional maturity is the nurse using? Select all that apply.
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1. Maintaining current skills
2. Being a lifelong learner
3. Actively identifying best practices
4. Overlooking one's own shortcomings
5. Willing to take responsibility for failures - ANSWER:1,2,3,5
Which informal power bases should the nurse use in the health care setting? Select all that apply.
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1. Expertise
2. Goodwill
3. Information
4. Observation
5. Collaboration - ANSWER:1,2,3
Which action ensures that a patient has consented to care?
1. Provide a consent form to sign to receive medications.
2. Ask the patient to sign a consent form to have dressings changed.
3. Discuss a consent form to sign to be turned in bed.
4. Explain how a dressing is to be changed. - ANSWER:4
For what can the nurse be held liable if forcibly inserting a nasogastric tube against a patient's wishes?
1. Negligence
2. Malpractice
3. Damages
4. Battery - ANSWER:4
For which patient would decision-making capacity likely be impaired? Select all that apply.
Note: Credit will be given only if all correct choices and no incorrect choices are selected.